Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Monday, August 27, 2007

Dinah sent me this link to a New York Times article about Robert Sillen, a former hospital administrator appointed to reform the California prison medical system. I know FooFoo5 has opinions about medical care in California prisons so I defer to his experiences there. I'm just here to think about change and how this is accomplished.

The Times article makes a point of highlighting Mr. Sillen's brash, at times profane, change-at-all-costs political incorrectness. As a Federally appointed health care receiver he has been put in charge of recreating the correctional health care system and he has threatened to break the bank to do it. Right off the top of my head, I have several thoughts about this.

My first thought is that I think I would like this guy. A straight-shooting administrator---even a profane one---would be a relief from the polished political bureaucracy that grinds ever-so-slowly and ineffectively. If he can get things accomplished by being that way, more power to him.

My second thought is that he probably won't last very long. Bureaucracy punishes efficiency, particularly when it's carried out without proper obeisance to the powers-that-be.

My third thought was triggered by this passage: "Mr. Sillen, whose $500,000 annual salary puts him among California’s highest paid public officials, said he had never visited a prison or thought much about the penal system until a recruiter called last year to persuade him to accept what the recruiter called a “mission impossible."

The man charged with reforming correctional health care has never been inside a prison. When he visited a penitentiary he was surprised to find "no sinks, no phones, no faxes, no way to communicate, no nothing". What? No phone? I'm shocked! Shocked, I tell you! As they used to say in the old Lost In Space show: "Danger, Will Robinson!" He is not a clinician, nor does he have correctional experience. Does anyone besides me think this is a bit odd? What were the Feds smoking? I hope he has clinical and correctional advisors he will listen to.

On the positive side, he's stating the obvious that everyone in free society needs to hear. He criticizes "tough on crime" policies that don't take into consideration the demand for health care services that these policies require. On the correctional administrative side, he criticizes prison officials who build new facilities without regard for treatment infrastructure. These are obvious things that need to be said loudly and repeatedly so no one forgets.

Acting as Milwaukee's health commissioner in 1894, he was responsible for the quarantine and vaccination policies during the smallpox outbreak. In addition to being rather antagonistic towards immigrants, Kempster was quite brash and neglected to grease social and political wheels of change when instituting the city's response. But, as you learn in any business management class, the biggest obstacle and saboteur of change is neither chance nor logistics, but rather resistance and limited on-the-ground support. Not surprisingly, his indelicacy did not help his cause; the result was anger, rioting, his impeachment, and a decades-long loss of the health department's power.

-"Part of the resistance to health department activities in 1894 were specific to Kempster; that is, he was a very unpopular man right from the start."-"I am here to enforce the laws, and I shall enforce them, if I have to break heads to do it." And, of course, it's the break heads that people heard. -"The question of the inhumanity of the laws I have nothing to do with."-Mobs of Pomeranian and Polish women armed with baseball bats, potato mashers...salt and pepper and butcher knives lay in wait all day for the isolation hospital van.

Potato mashers and salt? Then again, I'm sure you could tell us all a thing or two about resourcefulness. Anyway.

While he doesn't sound like he'll be starting prison riots, this may not end well. Efficient or not, the government's system of checked and distributed power is fundamentally at odds with mavericks. Going out of his way to step on toes is a foolhardy strategy that will likely beget either powerful and outspoken critics or a silent opposition willing to undermine his efforts. It will be fascinating to see this one play out."But for politics and bad beer, the matter would never have been heard of."

Thanks for that link; what a great story. This is directly relevant to correctional mental health care. The New York small pox incident emphasizes the importance of a multidisciplinary, non-discriminatory, non-punitive approach to public health and this exactly the approach to take in jail or prison psychiatry. All too often I hear that the approach to suicide prevention is a knee-jerk reaction to put someone in a suicide prevention cell rather than taking a non-punitive, educational approach (eg spread the word that it's 'safe' to say certain things, to be honest about feelings, and educate inmates about how to access services). I've seen too many inmates conceal their treatment histories out of fear of being put on observation status or of being discriminated against by being denied programs.

The other thing I liked about your link was the idea that women carrying potato mashers can change a system. Kind of gives a person hope.

Hmm, Clink, that makes me think of the website, Mashable, in a whole different way . . . oh, and it makes me hungry, too! Lol.

Mmm, cheese-topped baked potaters . . .

Oh yeah, where was I? I was at Target today, broswing the PC software/PC games, and saw Prison Tycoon TWO (as it proclaimed boldly on the box), amidst the various other Tycoons.

Now, I enjoy Rollercoaster Tycoon, and I ought to tell you about the old game, Theme Hospital, and the patients who'd come in with King Complex (they all looked like Elvis) and had to go to the psychiatrist's office to be cured. To this day, the word "Squits" is a term in our house, that we got from this game . . . Bloaty Head syndrome was fun, as was Invisible Man.

Whoops, anyway. There were some blurbs on the box as to various aspects of gameplay they thought were particularly fun and enticing; a couple of these made me think, Oh, boy . . . . geez. Anyway, I wonder if you've seen that, and whatcha think. I saw all manner of prison personnel mentioned, except psychiatrists.

But what on Earth did they plan to do with salt? Cause a shortage to make the horses spin out on ice? Pour it on potato masher wounds? It's not even combustible.Anyway, I'm not quite as pessimistic about his situation as I think I sounded...maybe he'll get something done and qualify for pension before they throw him out. Dear, that's not much of an improvement...but really, how long can he last?

Sarebear: No mention of 3rd Degree Sideburns or Spare Ribs?!I had to uninstall TH; it threatened to interfere with studying. And I still don't understand why they got so cold even though the grass was green and, at best, they were wearing light jackets and sweaters.

Another thought: it might be too time-consuming or off-topic, but it would be particularly interesting to hear a forensic psychiatrist's opinion on "Typhoid Mary." Specifically, perhaps regarding the lifetime "quarantine" of a healthy woman (while other carriers roamed free), her decision to secretly continue as a cook using aliases when she knew she carried the disease, and whether it is probable that more humane treatment in the initial stages would have prevented this decision and engendered cooperation (she certainly had a mind of her own). Funny how time (and/or different approaches) hasn't solved anything, e.g. "gift givers," the XDR-TB guy, and the WHO's thwarted polio eradication.

I did like shooting the mice, too, although it was hard to hit the quick lil buggers!

My hospitals were all cold, too. I delighted in placing a plethora of drink machines, and then watching the stampede towards the bathroom. If I was mean, I'd put it waaaay across the hospital campus . . .